Prevention, longevity and health system costs

Kailash Chand has a piece in the Guardian arguing that unless the NHS fundamentally changes its approach to focus on prevention rather than cure, it will not be financially sustainable. This reminds me that many well-informed people hold inconsistent views on prevention and health spending.

Ask most people why health spending is rising and they’ll tell you it’s because people are living longer. But why are we living longer? According to the Lancet, the main causes are falling tobacco use in men – the result of a hugely successful public health campaign to prevent smoking-related diseases – and falling cardiovascular mortality – which is closely related to how much exercise we do. So prevention is a major driver of people living longer, and people living longer is leading to higher health care costs. Does that mean that prevention is bankrupting the NHS?

We can begin to unscramble this mess when we realise that mostprojectionsof health spending estimate that the contribution of ageing populations to spending growth is quite small, because as people live longer lives they are also healthier at any given age. This is reflected in the fact that a large proportion of health care costs relate to the last few years of someone’s life, however long that life is. An 85-year-old has on average a third of their health care costs still to come, but someone who dies younger doesn’t avoid these costs, they just incur them earlier.

So dying is expensive, but not all deaths are equally dear. A recent US study found that dementia is the most expensive way to die, once social care and out-of-pocket spending are factored in. This is bad news because we don’t really know how to prevent dementia. There are some promising interventions, and recent evidence suggests that age-specific rates might be falling, but the evidence that we can prevent dementia is currently fairly weak. The risk of developing dementia rises rapidly with age, so it’s plausible that if we prevent people from dying of other things then they will live long enough to develop dementia and end up costing the NHS more.

Now I’m not really trying to argue that prevention increases costs. It’s very complicated to work that out and, at a whole system level, empirical evidence is hard to come by. Moreover, there are some areas where prevention does seem to save money. A recent evaluation of diabetes prevention in the NHS found that it was likely to be cost saving (after 12 years) – and to be fair, diabetes is one of the examples that Kailash cites. Targeted interventions like this, especially those focusing on diseases like diabetes that don’t kill us but cost money, could help with sustainability. But it’s far from clear that a system-wide shift towards prevention is going to stop health spending from going up.

This is no reason not to do more prevention, of course. Living longer and with fewer diseases is a great thing in itself and if preventive interventions can help us to do that then we should implement them, whether they are cheaper or more expensive than our current approach to health care.

But acting as if prevention (or integration, or anything else) is the answer to all of our concerns about the sustainability of health spending is not helpful. It reinforces the idea that rising health spending is a symptom of failure and always bad – but if what we get for the money is longer, healthier lives, it might well be worth it. And in doing so it lets the current government off the hook for their persistent underfunding of services and distracts from more important questions. If we want the NHS to meet the needs of an ageing population and provide us with the latest treatments, we might just have to accept that this means putting in more public money and paying for this through higher taxes.